“The treatment options for sufferers of GERD are increasing. The surgery to correct refractory cases is becoming less major with a faster recovery. Also the incidences of side effects of the Proton Pump Inhibitor medications is increasing, now including central nervous system problems. I included this here because the improvements in treatments is not widely known.” Bill Chesnut, MD
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Surgical options correct the cause of reflux
The surgical options attack the actual cause of the problem – the dysfunction of the lower esophageal sphincter (LES). Each attempts to correct the problem rather than covering it up with PPIs. I will summarize every available alternative and encourage further investigation of each.
Nissen fundoplication
Considered the “gold standard” of surgical antireflux therapy is the laparoscopic Nissen Fundoplication. This procedure restores the function of the LES by wrapping a portion of the upper stomach loosely around the lower esophagus. It is performed under general anesthesia using minimally invasive techniques. Five 1/2-1 inch incisions are required and it necessitates a one-day hospital stay. A “soft food” diet is typically suggested initially with gradual resumption to a normal diet taking 6-12 weeks. Although this is not a difficult procedure, it has its nuances and must be performed by a surgeon experienced in this procedure for optimal results. This operation stops the reflux in approximately 80-85% of patients, returning the pH test to normal.
This procedure eliminates the need for PPIs in most patients with the most well performed studies showing approximately 90% of surgical patients do not require those medications. Approximately the same number indicate that they are satisfied with the procedure in the 5-10 year time frame.
Even though the satisfaction rate is great, there are side effects with this procedure including swallowing difficulty (2-5% of patients), bloating and diarrhea to various degrees (10-20% of patients), and the inability to belch and vomit (30% of patients). These side effects seem to vary with the experience of the surgeon. In good hands, this is a proven, effective alternative to PPI therapy. Susan should also understand that a Nissen procedure can repair even the largest of hiatal hernias.
LINX Reflux Management System
Last year, the FDA approved a new procedure called the LINX Reflux Management System. This procedure places a magnetic bracelet around the lower esophagus to “augment” the failed LES. This is a minimally invasive technique and is typically completed in about 30 minutes. A regular diet and full activity is immediately resumed and the reflux is stopped approximately 70% of the time without the typical side effects associated with a Nissen procedure, except that a small number of recipients have difficulty swallowing.
The latest study of 100 patients showed 85% have eliminated PPIs after 3-5 years and 94% would recommend the procedure to a friend. Only 2% had swallowing difficulty, which was corrected with a simple non-surgical dilation (gentle stretching of the esophagus.) This procedure is available at a limited number of select locations in the US.
Incisionless procedures
Two procedures are available that are performed orally and do not require incisions. The TIF procedure, also know as the Esophyx procedure, and the Stretta procedure are both performed through the mouth. Since no incision is required, many individuals find this an attractive feature for both procedures. These two procedures do not have a predictable effect on eliminating reflux and studies have conflicted on the ability of patients to eliminate their PPI use. Many recipients report an improved “quality of life” although there is a concern that the elimination of reflux is not predictable and PPIs may be required long-term for some. In the only 10-year study on Stretta available, only 23% remained off PPIs at 10 years. As is the case with Nissen procedures, the skill set of the surgeon is an important factor is successful outcomes. Also, according to several surgeons, patient selection is an important variable as well.
Weigh your options
As discussed, there are alternatives to long-term PPI use to GERD. These treatment alternatives are becoming more attractive and receiving more interest today as consumers become more aware of the potential for negative long-term side affects from PPIs. For Susan, the best non-medical procedure seems to be the laparoscopic Nissen fundoplication since she describes a hiatal hernia. If it is greater than 3 cm in size, Nissen is the only recommended choice. If the hernia is less than 3cm, all of these procedures are options.